Are hospitals benefiting from the Medicaid expansion?

CEDAR RAPIDS - A little more than a year into the Iowa Health and Wellness Plan - Iowa's answer to Medicaid expansion - Cedar Rapids's hospitals say they've seen a decrease in the number of uninsured patients to whom they're providing care.

And while it's still too early to tell what kind of impact the Medicaid expansion, and even the Affordable Care Act (ACA), will have on their bottom lines, they're already seeing what they perceive to be positive changes.

This appears to be on par with what some studies have indicated is happening in hospitals across the country.

According to a September 2014 study by PwC's Health Research Institute, the growth in the 26 Medicaid-expansion states and Washington, D.C., starkly contrasts the experience in the 24 states that did not expand the program.

Hospitals in non-expansion states continued to see 'flat or sagging admission rates and little reduction in the number of uninsured, largely non-paying patients.”

Since the start of the health care plan in January 2014, more than 115,000 Iowans have signed up for coverage through Feb. 6, according to Iowa Department of Human Services (DHS) figures.

Here in the Corridor, more than 3,600 people have enrolled in the state insurance plan in Johnson County and more than 9,000 have enrolled in Linn County.

And DHS said in December that tens of thousands of people enrolled in the plan are now accessing preventive care services, including wellness exams and risk assessments, which can save the state and hospitals money.

Milton Aunan, senior vice president and chief financial officer at UnityPoint Health-St. Luke's Hospital, said the hospital does not have all its 2014 financials complete and audited, but it has seen a noticeable decrease in the number of uninsured patients receiving treatment.

'Between 2013 and 2014 there has been a decrease of approximately 50 percent in the number of self-pay patients treated at St. Luke's,” he said in an email. 'We've also noted a 30 percent increase in individuals covered by Medicaid, which seems to indicate more patients are seeking coverage and are eligible for coverage.”

St. Luke's also has seen a reduction in uncompensated care, he said, which may be attributed in part to the ACA.

Mercy Medical Center in Cedar Rapids has seen a 4 to 5 percent increase in Medicaid patients, said Nathan Van Genderen, executive vice president and chief financial officer. Before the expansion, Medicaid patients made up 7 to 8 percent of Mercy's business and now they comprise about 12 percent, he said.

At the same time, Mercy also has seen a 1 percent decrease in the number of uninsured patients it cares for.

'That's good on the surface,” he said. 'More people having insurance is a good thing.”

Overall, the hospital has seen a drop in the amount of uncompensated care it provides, Van Genderen noted, but the trend of more patients having plans with large out-of-pocket maximums means the hospital still is awarding a quite a bit of charitable care.

Still, more patients - both with Medicaid and with private insurers - are accessing the hospitals services, which is having a positive effect on Mercy's bottom line. Van Genderen said the hospital has seen its revenue increase over the past six months.

'But you can't contribute all of that to the Medicaid expansion,” he said. 'It's coming from all of the folks accessing health care.”

To help further cut costs, Mercy and the University of Iowa Hospitals and Clinics entered into an agreement with the state in 2014 to create a Medicaid Accountable Care Organization. ACOs are groups of hospitals or care providers that offer coordinated care to avoid duplication of services and prevent medical errors.

'We're trying to take that ACO ...

concept and implement that into the Medicaid patient population as well to better track patients preventive care services,” Van Genderen said.

Reducing the number of costly dental procedures

Iowa is one of a handful of states to include a dental component in its Medicaid expansion health plans. Those insured in the Dental Wellness Program have access to core services, including exams and cleaning as well as emergency services.

And the plan incentivizes more complex work, such as restorative services, root canal care and gum treatment, which are earned by completing a recall exam within six to 12 months of an initial exam.

'We want to change the behavior of a population who has not received oral care regularly,” said Jeff Russell, chief executive officer of Dental Dental, the insurer for the Dental Wellness Plan.

More than 35,000 Iowans already have received a service and about 15,000 have had a risk assessment, Russell said.

Additionally, about half of Iowa's dentists have opted to take on these new patients, in part because Delta Dental is offering a higher reimbursement than Medicaid typically does.

'We're pretty excited about those numbers,” he added.

The risk assessments provide Delta Dental with a significant amount of data, Russell said.

'We've found we can bundle this population into thirds,” he said. 'The top third (are) regular goers who are actively managing their care. The bottom third have significant issues but are hard to move to action.

'We see an opportunity in that middle third, who have expressed interest in receiving care.”

The insurer is incentivizing dentists to perform risk assessments by offering bonus payments - the first of which will go out in April. Russell hopes this will spur more dentists to perform the assessments in the future.

A long-term goal of the Dental Wellness Plan is to reduce the number of emergency room visits for dental pain in Iowa hospitals.

Delta Dental said that in 2007, there were 10,000 dental related emergency room visits in Iowa - costing the state $5 million. There were another 14,000 visits in 2009.

'We want to get folks to see a dentists on a regular basis, which would help reduce the number of costly dental procedures,” he said.